the virtual immunization communication (vic) network is a ...dec 18, 2013 · additional...

The Virtual Immunization Communication (VIC) Network is a project of the National Public Health Information Coalition (NPHIC) and the

California Immunization Coalition, funded through a cooperative agreement with the Centers for Disease Control and Prevention.

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Webinar Objectives• Discuss a framework for thinking about vaccine

acceptance and hesitancy • Review findings from CDC research about vaccine

acceptance and hesitancy in the past several years • Share how research findings have informed CDC's

communication efforts

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Lessons Learned on Vaccine Hesitancy and Acceptance

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A nationwide ‘virtual’ immunization community of health educators, public health communicators and others who promote immunizations.

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Welcome to the Webcast!We Will Be Starting Momentarily.

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TITLE of PRESENATIONWelcome

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Anne Schuchat, M.D.Director, National Center for Immunization and Respiratory DiseasesCenters for Disease Control and PreventionRear Admiral, US Public Health Service

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Glen Nowak, PhDProfessor of Advertising and Public Relations and Director of the Grady College's Center for Health and Risk Communication at the University of Georgia

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Allison Kennedy Fisher, MPHEpidemiologist, CDC's National Center for Immunization and Respiratory Diseases, Health Communication Science Office (HCSO)

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Jenny Mullen, MPHHealth Communication Specialist and Team Lead for the Childhood Immunizations Communication Team, NCIRD's Health Communication Science Office

Summary of CDC Research and Lessons Learned on Vaccine

Hesitancy and Acceptance among Parents of Infants and Young

ChildrenAnne Schuchat, MD

Glen Nowak, PhDAllison Fisher, MPHJenny Mullen, MPH

VIC WebinarDecember 18, 2013

National Center for Immunization & Respiratory DiseasesHealth Communication Science Office

Objectives

Discuss a framework for thinking about vaccine acceptance and hesitancy

Review findings from CDC research about vaccine acceptance and hesitancy in the past several years, including how those research findings have informed our communication efforts

Outline recommendations for future research and activities in this area

FRAMEWORK

• Low disease awareness = increased focus on vaccine risks

• Low tolerance for vaccine risks

• Full and complicated immunization schedule

• Vaccines are often mandated

• Spectrum of parent attitudes and beliefs

Factors Related to Current Vaccine Recommendations and Successes

Vaccine Acceptance

• “A targeted population’s beliefs, confidence and voluntary intentions in those making the recommendation” (Cooper, Larson and Katz 2008)

• Vaccine coverage may or may not be an adequate proxy for vaccine acceptance– Likely an excellent indicator when coverage rates are very

high• Not likely a good indicator if external factors or

barriers exist • Parent questions or concerns can be a poor

indicator – Many parents have questions or concerns related to

vaccines or recommended immunizations, yet still immunize

“Confidence” and “Hesitancy”

• Antecedents and determinants of vaccine acceptance

• Confidence – amount/level of trust and faith– In safety of the vaccine and immunization recommendation– In value/benefits of the vaccine and immunization

recommendation– In those who made the recommendation and administer the

vaccination• Hesitancy – willingness/reluctance to receive a

recommended vaccination• More confident, less hesitant

Cognitive Factors that InfluenceVaccine Acceptance

Strong vaccine acceptance is associated with. . .

• Sufficient knowledge about the vaccine and immunization recommendations;

• An understanding of health and disease that is in line with mainstream medicine;

• Having little or no doubts regarding vaccine safety;

• Believing in the efficacy of the vaccine (i.e., that the vaccine will provide protection, benefits);

• Trusting/having confidence in health care providers

Additional Implications• “Vaccine hesitancy” can be fostered by. . .

– Lack of knowledge – e.g., about diseases, vaccination– Concerns – e.g., number and timing of vaccinations, vaccine

safety– Desire to be active participant in child’s health care – e.g., to

“manage” schedule– Reluctance – e.g., to have child receive vaccinations when ill

• Addressing “hesistancy,” fostering “confidence,” and achieving high “acceptance” is not as easy as one desires– Requires building high levels of awareness and knowledge– Research (e.g., to identify where populations/groups are and

distribution along the continuum)

VACCINATION COVERAGE IN THE UNITED STATES

Estimated Vaccination Coverage,among Children 19-35 Months of Age, 1991-2011

Hib (3+)Hep B (3+)

PCV (4+)

Varicella (1+)

DTP/DTaP(3+)

* Source: NHIS (1991-1993); NIS (1994-20101 children 19-35 months† Target is 80 percent for Rotavirus§ Full series Hib (≥3 or ≥4 doses, depending on product type received). Brand of Hib vaccine received was not collected on the NIS prior to 2009.

Rotavirus

HP 2020 Target†

MMR (1+)

Vaccination Coverage in the United States

• 2012 National Immunization Survey– Proportion of kids nationally with no vaccine

doses is 0.8% (this has been consistent over time)

• Varying estimates of delay/refusal– Depends somewhat on method and population– In a 2012 CDC survey, 11.7% of parents of young

children self-reported some form of intentional vaccine delay and/or refusal

Source: 1) MMWR, 2013. 62(36):733-740; 2) 2012 National Poll of Parents, CDC unpublished

Percent Exempt

< 2%

2 - 4%

5 - 10%

> 10%

No Data Reported

Data Source: The average percentage of Kindergarteners who have one or more exemptions to school-entry required vaccines as reported by schools in each county. WA State Department of Health Office of Immunization Child Profile, Created with ArcGIS 10.0 DOH 348-313 June 2012

WA State Kindergarten Immunization Exemption Rates by County School Year 2011-2012

Statewide AverageExemption rate: 4.5%

KNOWLEDGE AND ATTITUDES

Research with Health Care Professionals

Completed 2008 in-depth interviews with pediatricians and

family physicians 2009 survey of pediatricians and family

physicians (partnership with U of Colorado) 2010 pilot evaluation of educational materials with

WA state health care professionals 2010 in-depth interviews (IDIs) to discuss provider

resources

Research with Health Care Professionals Guiding Principles and Lessons Learned Strong support among health care professionals

for the existing immunization schedule Bottom line is that kids are getting immunized but

discussion and education are taking longer than in the past

Health care professionals are still the most trusted source of vaccine information and advice for most parents

Educational materials should supplement—not replace—conversations between health care professionals and parents

What do pediatricians and family physicians think?

• The majority of physicians surveyed felt comfortable addressing parents’ vaccine questions and concerns, but reported that time and other health priorities were the most significant barriers to doing so effectively

• Physicians reported that in their experience, personal strategies were the most effective in communicating with vaccine-hesitant parents– Stating that they had or would vaccinate their own

children– Discussing their own experience in practice with the

safety of vaccines

Source: Kempe et al. American Journal of Preventive Medicine. 2011;40(5):548-555.

Research with Parents

Completed 2008, 2009, 2010 HealthStyles mail surveys of parents 2008 and 2009 focus group research with moms 2008 online testing of draft educational materials with

moms 2010 and 2012 national polls of parent vaccine

attitudes and behaviors 2010 cognitive interviews and focus groups with

moms to test readability of Vaccine Information Statements

2011 focus groups and intercept interviews with parents to discuss vaccination barriers and facilitators, and to test message concepts

2011and 2012 ConsumerStyles Internet survey of parents

Research with Parents

Guiding principles and lessons learned Most parents nationally are confident in vaccine

safety, and either have already vaccinated or plan to fully vaccinate their child

All parents have at least some questions or concerns about infant immunization (pain, side effects, number, and timing are consistently the most common)

A child’s healthcare provider is generally the most important source of vaccine information; however, moms want to hear consistent things from multiple sources they deem credible

Educational materials with personal stories and information about vaccine preventable diseases are well-received

2008 Focus Groups: Role of Vaccines in Child Health

Mothers consistently listed doctor visits and immunizations as among the most important things you can do to keep your children healthy

Some mothers questioned the need for vaccinations, based on concerns about efficacy or a perceived low prevalence of VPDs

Please indicate how confident you are in each of the following: The safety of routine childhood

vaccinations

Not at allConfident

VeryConfident

Perc

ent o

f Res

pond

ents

Source: 2012 Consumerstyles Survey

Getting my child immunized is the right thing to do.

StronglyDisagree

StronglyAgree

Perc

ent o

f Res

pond

ents


It is important to vaccinate my child in order to prevent the spread of disease in my community.

StronglyDisagree

StronglyAgree

Perc

ent o

f Res

pond

ents


Thinking of your youngest child’s next vaccination appointment, are you:

%

Not at all anxious 73.4

A little anxious 18.5

Somewhat anxious 5.9

Very anxious 2.2

Source: 2012 National Poll of Parents, CDC unpublished

2009 Focus Groups: Vaccine Schedule and Timing

Mothers were generally knowledgeable about the timing of vaccines

Many reacted negatively to receiving multiple injections during one visit

Most were vaccinating according to the recommended schedule, but several across race/education/location segments reported (generally short-term) spreading vaccinations Variety of reasons for spreading: concerns about children’s

ability to “handle” multiple vaccines; concerns about ability to pinpoint source of adverse events; some concerns about pain

2009 Focus Groups: VPD Knowledge and Beliefs

After reading brief descriptions of the 14 VPDs, many mothers said they were surprised to find out how many could be fatal, including some they previously did not consider serious

Many mothers shared personal stories that impacted their view of particular VPDs Some knew a baby who had whooping cough (heightened

their perception of severity) Most talked about their own experience with flu or

chickenpox (lessened their perception of severity)

What questions do you typically ask your child’s health care provider before your

child gets a vaccine?2011

Weighted Percent

Which vaccines will my child get today? 70.3

How many vaccines will my child get today? 66.7

How likely is there to be a side effect? 57.3

What are the side effects I should look for? 50.7

What is normal to expect the day after? 46.5


Which concerns, if any, do you have about childhood vaccines?

2012 Weighted Percent

I have no concerns about childhood vaccines 45.5

My child getting too many vaccines in one doctor’s visit

22.8

Children get too many vaccines during the first two years of life

22.8

The ingredients in vaccines are unsafe 19.2

Vaccines causing fevers in my child 16.8


How comfortable are you with the recommended number of childhood vaccines in the first two years

of a baby’s life?

Perc

ent


What is the most number of vaccine shots you are comfortable with your youngest child getting in one

doctor’s visit?

Perc

ent


If your doctor or other health care provider told you that it was safe to vaccinate your youngest child when

he or she had a mild illness, like a cold, would you agree to vaccinate him or her?


2008 Focus Groups: Sources of Vaccine Information

Moms most often turn to their children’s doctors if they have questions

The Internet also was a frequently cited source for information, primarily through the use of search engines (e.g., Google)

Family, friends, and peers also cited as sources of information

Moms want to hear consistent things from multiple sources they deem credible

Thinking about your youngest child, in general, how much vaccine information did you try to find before

his or her vaccination visits?


What are the three most important sources of information that have helped you make decisions

about your youngest child’s vaccinations?

• Child’s health care provider (90.2%)• Family (52.6%)• Child’s other parent (32.2%)• American Academy of Pediatrics (28.9%)• CDC (26.7%)• Friends (24.9%)• Internet (22.5%)• Traditional media (6.4%)• Complementary healthcare provider (2.1%)


When asked about the healthcare practitioner (HCP) who they spoke to most often about vaccines, most parents agreed or strongly agreed that the HCP…

• Spent as much time as they needed to get answers

• Made them feel involved in the vaccination decision

• Answered their questions• Helped them understand the diseases vaccines

prevent

This is still true among parents who reported refusing and/or delaying at least one vaccine


2009 Focus Groups: Advice for Other Moms

Participants were asked what advice about vaccination they would give to another mother Most common—vaccines are important Talk to health care professionals Overarching theme of personal choice regarding

necessity and/or schedule:• Some hesitancy to give other mothers advice about

vaccines• “Do your research”• “Trust your instincts”

PARENTS WHO DELAY AND REFUSE VACCINES

So far, when vaccines have been recommended for your youngest child at a check-up, have you gotten them all at those visits, or are there any vaccines that he or she did not get at the time that they

were recommended? (n=2,603)

%My child received all of his/her vaccines at the time(s) they were recommended

86.1

My child did not receive all of his/her vaccines at the time(s) they were recommended by I am actively working to catch him or her up

2.2

I chose to delay, or get later, one or more, but not all of the recommended vaccines at the time(s) they were recommended

5.5

I chose to delay all of the recommended vaccines at the time(s) they were recommended

0.4

I chose to refuse, or never get, one or more, but not all, of the recommended vaccines at the time(s) they were recommended

2.4

I chose to refuse and delay some of the vaccines for my child at the time(s) they were recommended

2.1

I chose to refuse all of the recommended vaccines at the time(s) they were recommended

1.4


Of parents refusing all vaccines: What is the main reason you have refused, or not gotten, any

vaccines yet for your youngest child? (n=49)

%Philosophical and/or religious reasons 23.0Fear of side effects (fever, autism, or other conditions, etc.) 20.2

Other 17.6Vaccines have not been thoroughly tested 15.4Vaccines and or their ingredients aren’t safe (not “green” enough) 15.2

It’s better for this child to get the disease naturally, by getting the actual disease 6.3

Too many vaccines/medicines 2.3


Of parents refusing one or more, but not all, vaccines: Please select the main reason for refusing the recommended

vaccine(s) for your youngest child? (n=67)

%Other 24.5It’s better for this child to get the disease naturally, by getting the actual disease 21.9

Philosophical and/or religious reasons 15.1Fear of side effects (fever, autism, other conditions, etc) 14.2Vaccines have not been thoroughly tested 11.6I feel my child is too young to receive vaccines 7.4Too many vaccines/medicines 6.0Too many shots (injections) 3.2Vaccines don’t work 2.7Vaccines and/or their ingredients aren’t safe (not “green” enough) 2.0

Vaccines are not deeded due to improved treatments, sanitation, healthcare system, etc. 1.6

I know a child who has been injured by this vaccine 1.3


Of parents refusing one or more, but not all: Please select the vaccine(s) that you have refused, or declined, at

the recommended time(s) for your youngest child (n=67)

%Influenza (flu) 78.8Varicella (Chicken Pox) 42.1Hepatitis A 33.6Inactive Poliovirus (IPV) 29.3Measles, Mumps, Rubella (MMR) 25.9Rotavirus (RV) 24.8Haemophilus Influenzae type B (Hib) 24.2Hepatitis B 15.5Pneumococcal (PCV) 16.7Diphtheria, Tetanus, Pertussis (DTaP) 13.9


Of parents delaying vaccines: Please select the main reason for delaying the recommended

vaccine(s) for your youngest child? (n=206)

%Fear of side effects (fever, autism, other conditions, etc.) 35.0

Too many vaccines/medicines 19.8Other 18.1Too many shots (injections) 16.5I feel my child is too young to receive vaccines 5.8

I am unable to get to the appointment 2.8This child was sick at the time 1.8I know a child who has been injured by this vaccine 0.2


Of parents delaying vaccines: Please select the vaccine(s) that you have put-off, or delayed, for your youngest child (n=206)

%Influenza (flu) 53.8Measles, Mumps, Rubella (MMR) 39.2Varicella (Chicken Pox) 37.6Hepatitis B 33.7Hepatitis A 28.0Pneumococcal (PCV) 26.0Haemophilus Influenzae type B (Hib) 23.6Diphtheria, Tetanus, Pertussis (DTaP) 22.3Inactive Poliovirus (IPV) 21.7Rotavirus (RV) 19.5


Parents who Delay and/or Refuse Vaccines The 2009 National Immunization Survey (NIS) found

that parents who delayed and refused vaccines were significantly less likely than parents who did not delay or refuse vaccines to believe: Vaccines are necessary to protect the health of children Their child might get a disease if they aren't vaccinated Vaccines are safe

Children whose parents delayed and refused vaccines were also significantly more likely to: Live in a household with an income greater than 400% of the

Federal Poverty Level Have a mother who was married, over 30 years of age, a

college graduate, speaks English, or is non-Hispanic White Have private health insurance Live in a household with 4 or more children

Source: Smith, et al. Public Health Reports. 2011; 126(S2): 135–146.

Parents who Delay and/or Refuse Vaccines

Another study from the 2003 NIS found that: Concerns about vaccine safety and a child’s

acute illness were the most common reasons for delay

Parents who reported intentionally delaying vaccines were less likely to have children who were up to date on the routine vaccination series at 19 and 24 months

Source: Smith, et al. Public Health Reports. 2010;125(4):534-541.

RESEARCH TO PRACTICE

Key Drivers to Communication Planning

Vaccine safety issues are a concern for many parents. Risk communication approach is needed to maintain trust.

The facts don’t speak for themselves. Personal accounts from peers or health care professionals are persuasive and memorable.

There is a spectrum of parental attitudes, beliefs, and behaviors requiring some tailoring and layering of communication practices and materials.

Health care professionals play the most important role in addressing parents’ questions and concerns.

Recommendations from providers are persuasive. Reinforcing the social norm around vaccination is

important.

“Provider Resources for Vaccine Conversations with Parents”

• Developed with partners: AAP and AAFP• Primary Target Audience: Health Care

Professionals – Provide information to help when talking to parents

about vaccines, vaccine-preventable diseases, and vaccine safety

– Dual purpose resources hcps can provide to meet parents information needs

• Based on formative research• Using risk communication principles• Extensively reviewed by subject matter experts

Talking with Parents about Vaccines for Infants

• During the Office Visit– Take time to listen– Solicit and welcome questions– Keep the conversation going– Use a mix of science and

personal anecdotes– Acknowledge benefits and risks– Respect parents’ authority

• After the Office Visit– Document parents’ questions

or concerns– Follow up a few days after the

visit

Materials: Provider Resources Understanding Vaccines and Vaccine Safety

How Vaccines Work The Recommended Childhood Immunization Schedule Ensuring the Safety of U.S. Vaccines Understanding the Vaccine Adverse Reaction Reporting

System Understanding MMR Vaccine Safety Understanding Thimerosal, Mercury, and Vaccine Safety The Advisory Committee on Immunization Practices

Diseases and the Vaccines that Prevent Them 14 vaccine-preventable disease sheets, each with 2 versions

(one for high-information seeking parents and the other with basic information); Basic sheets are also available in Spanish

If You Choose Not to Vaccinate, Understand the Risk and Your Responsibilities

Provider-Targeted Materials

Topics of concern/interest to providers and parents

Summary of key points

Co-branded with AAFP and AAP

The science

Q&A format

Date

Parent-Targeted Materials (1)

Current stories from families affected by VPDs

Vaccine risks and benefits

VPD risks

Quotes from health care professionals

Co-branded with AAFP and AAP

References

Date

Parent-Targeted Materials (2)• Health care

professionals requested more plain-language pieces for parents

• More basic overview of disease and vaccine

• Most have no story (or an abbreviated version)

• Clearly shows benefits and risks

• Available in Spanish and English

www.cdc.gov/vaccines/conversations

Where to Find these Resources

Other Parent-Targeted Resources

Want sample tweets?

Besides #measles and #polio, what other diseases is your vaccinated child protected against? http://1.usa.gov/InPEhA

What about Facebook posts?

You baby’s well-child visits can be stressful for you and your child, but there are ways to make them go easier. Get useful tips for soothing your baby when he gets shots by visiting CDC’s new vaccine website for parents: http://www.cdc.gov/vaccines/parents/tools/tips-factsheet.html

Parent Friendly Website:www.cdc.gov/vaccines/parents

Media Campaign Targeting Parents

• English and Spanish print ads, radio and television PSAs, and matte articles

• Launched in April 2012 and rolled out through Summer and Fall 2012

• Released new materials in 2013

• Directs parents to parent-friendly website and materials

Goals of Campaign

• Reinforce the social norm to vaccinate• Increase awareness of vaccine-preventable

diseases• Increase awareness of disease protection

benefits of vaccines• Empower parents to make the choice to

immunize their children

English TV PSA:Immunization. Power to Protect.

• Broadcast quality • Downloadable: www.cdc.gov/vaccines/cdcmediaresources/• Partners can pitch and place with local media

Spanish TV PSACon salud, todo es posible. Vacune a sus hijos.

• Broadcast quality • Downloadable:

www.cdc.gov/vaccines/cdcmediaresources/

• Partners can pitch and place with local media

RECOMMENDATIONS

Summary, Recommendations, and Future Research

Remember that parents fall along a spectrum; this is not an “either/or” decision

The healthcare professional is the most important source of information, but don’t ignore other social influences

Questions and concerns do not equal lack of confidence; vaccinating is still the social norm

There is no quick fix media message; grassroots education and partnerships are the key

Summary, Recommendations, and Future Research

We need a better understanding of the impact of social media (in general, not just in vaccines)

We also need a better understanding of vaccine delay—especially intentional vs. circumstantial

We need to learn more about differences at the local level

We should also work to standardize the measures and define what “success” is

What We’re Asking You To Do:

SHARE “Provider Resources” with parents and health care professionals

www.cdc.gov/vaccines/conversations

GIVE a strong recommendation for on time childhood immunization and welcome parent questions

DOWNLOAD AND PLACE radio and TV PSAs locallyhttp://www.cdc.gov/vaccines/events/niiw/web-

etools.html?tab=2#TabbedPanels1

PUBLISH print ads and drop-in articles in your parent publications(s)

http://www.cdc.gov/vaccines/events/niiw/media-tools.html

COLLABORATE with us to expand the campaign’s reach

Jenny Mullen ([email protected])

• Michelle Basket• Mary McCauley• Kris Sheedy • Allison Fisher• Leslie Rodriguez• Jenny Mullen• Brian Katzowitz• Jackie McClain• Cookie Filomeno• Maureen Marshall• Alison Patti• Jeanette St. Pierre• Cindy Fowler• Kate LaVail• Anne Schuchat • Melinda Wharton• Cathy Hogan• Dwan Hightower• Alan Janssen• Janine Cory

Acknowledgements• Larry Pickering• Jim Singleton• Stacie Greby• Phil Smith • Families who graciously

shared their stories • American Academy of Family

Physicians• American Academy of

Pediatrics• AED/FHI-360• Washington State DOH• Yabo Akinsanya-Beysolow• Greg Armstrong • Bill Atkinson• Stephanie Bialek • Joe Bresee• Carolyn Bridges• Elizabeth Briere• Erin Burns• Rebecca Cabral

• Claudia Chesley• Tom Clark• Steve Cochi• Amanda Cohn• Fatima Coronado• Sandra de los Santos• Vance Dietz• Kathleen Gallagher • Sue Goldstein• James Goodson• Malaika Hilliard• Deborah Holtzman • Cynthia Jorgenson• Sunnah Kim• Andrew Kroger• Charlie Lebaron • Adriana Lopez• Stephanie Marshall• Eric Mast

Acknowledgements-Cont.• Nancy Messonier• Matt Moore• Gina Mootrey• Trudy Murphy• Umesh Parashar • Daniel Payne• Susan Redd• Susan Reef• Lance Rodewald• Dan Salmon• Belinda Schoof• Stephanie Schrag• Jane Seward• Elizabeth Sobczyk• Tej Tiwari • Gregory Wallace• Steve Wassilak • Donna Weaver• Herb Young

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for Immunization & Respiratory Diseases

Q & A Session

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Connect with the VICNetwork…

e-mail: [email protected]

Website www.VICNetwork.org

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Resources

Centers for Disease Control and Preventionwww.cdc.gov/vaccines

National Public Health Information Coalitionwww.nphic.org

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National Public Health Information Coalitionwww.nphic.org

California Immunization Coalition www.immunizeca.org

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